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Alcedo González J, Estremera-Arévalo F, Cobián Malaver J, Santos Vicente J, Alcalá-González LG, Naves J, Barba Orozco E, Barber Caselles C, Serrano-Falcón B, Accarino Garaventa A, Alonso-Cotoner C, Serra Pueyo J. Common questions and rationale answers about the intestinal bacterial overgrowth syndrome (SIBO). GASTROENTEROLOGIA Y HEPATOLOGIA 2024:502216. [PMID: 38852778 DOI: 10.1016/j.gastrohep.2024.502216] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/28/2024] [Revised: 05/15/2024] [Accepted: 05/24/2024] [Indexed: 06/11/2024]
Affiliation(s)
- Javier Alcedo González
- Servicio de Aparato Digestivo, Hospital Universitario Miguel Servet, Instituto de Investigación Sanitaria (IIS) Aragón, Zaragoza, España.
| | - Fermín Estremera-Arévalo
- Servicio de Aparato Digestivo, Hospital Universitario de Navarra, Navarrabiomed, Universidad Pública de Navarra - IdiSNA, Navarra, España
| | | | - Javier Santos Vicente
- Laboratorio de Neuro-Inmuno-Gastroenterología, Unidad de Investigación de Aparato Digestivo, Institut de Recerca (VHIR), Servicio de Aparato Digestivo, Hospital Universitario Vall d'Hebron, Barcelona, España; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (Ciberehd), Instituto de Salud Carlos III, Madrid, España
| | | | - Juan Naves
- Servicio de Aparato Digestivo, Hospital del Mar, Barcelona, España
| | - Elizabeth Barba Orozco
- Unidad de Neurogastroenterología y Motilidad, Hospital Clínic de Barcelona, Barcelona, España; Departamento de Gastroenterología, Universidad de Barcelona, Barcelona, España
| | | | - Blanca Serrano-Falcón
- Servicio de Aparato Digestivo, Hospital Universitario Virgen de las Nieves, Granada, España
| | | | - Carmen Alonso-Cotoner
- Laboratorio de Neuro-Inmuno-Gastroenterología, Unidad de Investigación de Aparato Digestivo, Institut de Recerca (VHIR), Servicio de Aparato Digestivo, Hospital Universitario Vall d'Hebron, Barcelona, España; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (Ciberehd), Instituto de Salud Carlos III, Madrid, España; Facultad de Medicina, Universidad Autónoma de Barcelona, Barcelona, España
| | - Jordi Serra Pueyo
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (Ciberehd), Instituto de Salud Carlos III, Madrid, España; Área de Aparato Digestivo, Hospital Universitario Vall d'Hebron, Barcelona, España
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Abstract
PURPOSE OF REVIEW This article aims to provide an up-to-date review of small intestinal bacterial overgrowth (SIBO), including etiology and risk factors, clinical manifestations, diagnostic evaluation for suspected SIBO, and therapeutic options. RECENT FINDINGS Recent advances in breath testing, capsule and urine-based testing have opened new avenues and improved diagnostic yield of SIBO. Nonantibiotic-based treatment strategies have shown promising results in initial trials. SUMMARY Small intestinal bacterial overgrowth (SIBO) is a condition defined by the excess bacteria or changes in bacterial composition of the small intestine. These are associated with various gastrointestinal (GI) symptoms such as bloating, abdominal distension, diarrhea, nutrient deficiencies, and even frank weight loss. Small bowel jejunal aspirate of >10 5 CFU/ml has traditionally been considered the gold standard for diagnosis. Glucose and lactulose breath testing have become more common in clinical practice as they are noninvasive, easily accessible, and have lower cost. Treatment focuses on the eradication of excess bacteria in the small bowel and is traditionally done with the use of oral antibiotics. Other emerging therapies may include probiotics, diet manipulation, and prokinetic agents.
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Affiliation(s)
- Hammad Zafar
- Department of Gastroenterology, Hepatology and Nutrition, Cleveland Clinic Florida, Weston, Florida, USA
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Abstract
Small intestinal bacterial overgrowth (SIBO) is a common, yet underrecognized, problem. Its prevalence is unknown because SIBO requires diagnostic testing. Although abdominal bloating, gas, distension, and diarrhea are common symptoms, they do not predict positive diagnosis. Predisposing factors include proton-pump inhibitors, opioids, gastric bypass, colectomy, and dysmotility. Small bowel aspirate/culture with growth of 10-10 cfu/mL is generally accepted as the "best diagnostic method," but it is invasive. Glucose or lactulose breath testing is noninvasive but an indirect method that requires further standardization and validation for SIBO. Treatment, usually with antibiotics, aims to provide symptom relief through eradication of bacteria in the small intestine. Limited numbers of controlled studies have shown systemic antibiotics (norfloxacin and metronidazole) to be efficacious. However, 15 studies have shown rifaximin, a nonsystemic antibiotic, to be effective against SIBO and well tolerated. Through improved awareness and scientific rigor, the SIBO landscape is poised for transformation.
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Duncanson K, Burrows T, Keely S, Potter M, Das G, Walker M, Talley NJ. The Alignment of Dietary Intake and Symptom-Reporting Capture Periods in Studies Assessing Associations between Food and Functional Gastrointestinal Disorder Symptoms: A Systematic Review. Nutrients 2019; 11:E2590. [PMID: 31661839 PMCID: PMC6893476 DOI: 10.3390/nu11112590] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2019] [Revised: 10/17/2019] [Accepted: 10/22/2019] [Indexed: 02/07/2023] Open
Abstract
Food ingestion is heavily implicated in inducing symptoms of irritable bowel syndrome (IBS) and functional dyspepsia (FD), which affect over one-third of adults in developed countries. The primary aim of this paper was to assess the alignment of dietary assessment and symptom-reporting capture periods in diet-related studies on IBS or FD in adults. Secondary aims were to compare the degree of alignment, validity of symptom-reporting tools and reported significant associations between food ingestion and symptoms. A five-database systematic literature search resulted in 40 included studies, from which data were extracted and collated. The food/diet and symptom capture periods matched exactly in 60% (n = 24/40) of studies, overlapped in 30% (n = 12/40) of studies and were not aligned in 10% (n = 4/40) of studies. Only 30% (n = 12/40) of studies that reported a significant association between food and global gastrointestinal symptoms used a validated symptom-reporting tool. Of the thirty (75%) studies that reported at least one significant association between individual gastrointestinal symptoms and dietary intake, only four (13%) used a validated symptom tool. Guidelines to ensure that validated symptom-reporting tools are matched with fit-for-purpose dietary assessment methods are needed to minimise discrepancies in the alignment of food and symptom tools, in order to progress functional gastrointestinal disorder research.
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Affiliation(s)
- Kerith Duncanson
- School of Health Sciences, Faculty of Health and Medicine, The University of Newcastle, Newcastle, NSW 2308, Australia.
- Priority Research Centre in Physical Activity and Nutrition, The University of Newcastle, Newcastle, NSW 2308, Australia.
- Priority Research Centre, Digestive Health and Neurogastroenterology, The University of Newcastle, Newcastle, NSW 2308, Australia.
| | - Tracy Burrows
- School of Health Sciences, Faculty of Health and Medicine, The University of Newcastle, Newcastle, NSW 2308, Australia.
- Priority Research Centre in Physical Activity and Nutrition, The University of Newcastle, Newcastle, NSW 2308, Australia.
| | - Simon Keely
- Priority Research Centre, Digestive Health and Neurogastroenterology, The University of Newcastle, Newcastle, NSW 2308, Australia.
- School of Biomedical Sciences and Pharmacy, The University of Newcastle, Newcastle, NSW 2308, Australia.
| | - Michael Potter
- Priority Research Centre, Digestive Health and Neurogastroenterology, The University of Newcastle, Newcastle, NSW 2308, Australia.
| | - Gayatri Das
- Priority Research Centre, Digestive Health and Neurogastroenterology, The University of Newcastle, Newcastle, NSW 2308, Australia.
| | - Marjorie Walker
- Priority Research Centre, Digestive Health and Neurogastroenterology, The University of Newcastle, Newcastle, NSW 2308, Australia.
- School of Medicine and Public Health, The University of Newcastle, Newcastle, NSW 2308, Australia.
| | - Nicholas J Talley
- Priority Research Centre, Digestive Health and Neurogastroenterology, The University of Newcastle, Newcastle, NSW 2308, Australia.
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Le Nevé B, Derrien M, Tap J, Brazeilles R, Cools Portier S, Guyonnet D, Ohman L, Störsrud S, Törnblom H, Simrén M. Fasting breath H2 and gut microbiota metabolic potential are associated with the response to a fermented milk product in irritable bowel syndrome. PLoS One 2019; 14:e0214273. [PMID: 30946757 PMCID: PMC6448848 DOI: 10.1371/journal.pone.0214273] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2018] [Accepted: 02/25/2019] [Indexed: 12/17/2022] Open
Abstract
OBJECTIVES Aim of this study was to assess the effect of a fermented milk product containing Bifidobacterium lactis CNCM I-2494 (FMP) on gastrointestinal (GI) symptoms and exhaled H2 and CH4 during a nutrient and lactulose challenge in patients with irritable bowel syndrome (IBS). METHODS We included 125 patients with IBS (Rome III). Fasted subjects were served a 400ml liquid test meal containing 25g lactulose. The intensity of eight GI symptoms and the amount of exhaled H2 and CH4 were assessed before and during 4h after meal intake. The challenge was repeated after 14 days consumption of FMP or a control product in a double-blind, randomized, parallel design. The metabolic potential of fecal microbiota was profiled using 16S MiSeq analysis of samples obtained before and after the intervention. RESULTS 106 patients with IBS were randomized. No difference between FMP or control groups was found on GI symptoms or breath H2 and CH4 in the whole cohort. A post-hoc analysis in patients stratified according to their fasting H2 levels showed that in high H2 producers (fasting H2 level≥10ppm, n = 35), FMP consumption reduced fasting H2 levels (p = 0.003) and H2 production during the challenge (p = 0.002) and tended to decrease GI discomfort (p = 0.05) vs. control product. The Prevotella/Bacteroides metabolic potential at baseline was higher in high H2 producers (p<0.05) vs. low H2 producers and FMP consumption reduced this ratio (p<0.05) vs. control product. CONCLUSIONS The response to a fermented milk product containing Bifidobacterium lactis CNCM I-2494 (FMP) in patients with IBS seems to be associated with the metabolic potential of the gut microbiota. TRIAL REGISTRATION ClinicalTrial.gov NCT01252550. These results were presented as congress posters at Digestive Disease Week 2016 in San Diego, USA and United European Gastroenterology Week 2016 in Vienna, Austria.
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Affiliation(s)
| | | | - Julien Tap
- Danone Nutricia Research, Palaiseau, France
| | | | | | | | - Lena Ohman
- Department of Immunology and Microbiology, Institute of Biomedicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Internal Medicine and Clinical Nutrition, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Stine Störsrud
- Department of Internal Medicine and Clinical Nutrition, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Hans Törnblom
- Department of Internal Medicine and Clinical Nutrition, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Magnus Simrén
- Department of Internal Medicine and Clinical Nutrition, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Center for Functional Gastrointestinal and Motility Disorders, University of North Carolina, Chapel Hill, North Carolina, United States of America
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Hungin APS, Mitchell CR, Whorwell P, Mulligan C, Cole O, Agréus L, Fracasso P, Lionis C, Mendive J, Philippart de Foy J, Seifert B, Wensaas K, Winchester C, de Wit N. Systematic review: probiotics in the management of lower gastrointestinal symptoms - an updated evidence-based international consensus. Aliment Pharmacol Ther 2018; 47:1054-1070. [PMID: 29460487 PMCID: PMC5900870 DOI: 10.1111/apt.14539] [Citation(s) in RCA: 77] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2017] [Revised: 09/15/2017] [Accepted: 01/05/2018] [Indexed: 12/11/2022]
Abstract
BACKGROUND In 2013, a systematic review and Delphi consensus reported that specific probiotics can benefit adult patients with irritable bowel syndrome (IBS) and other gastrointestinal (GI) problems. AIM To update the consensus with new evidence. METHODS A systematic review identified randomised, placebo-controlled trials published between January 2012 and June 2017. Evidence was graded, previously developed statements were reassessed by an 8-expert panel, and agreement was reached via Delphi consensus. RESULTS A total of 70 studies were included (IBS, 34; diarrhoea associated with antibiotics, 13; diarrhoea associated with Helicobacter pylori eradication therapy, 7; other conditions, 16). Of 15 studies that examined global IBS symptoms as a primary endpoint, 8 reported significant benefits of probiotics vs placebo. Consensus statements with 100% agreement and "high" evidence level indicated that specific probiotics help reduce overall symptom burden and abdominal pain in some patients with IBS and duration/intensity of diarrhoea in patients prescribed antibiotics or H. pylori eradication therapy, and have favourable safety. Statements with 70%-100% agreement and "moderate" evidence indicated that, in some patients with IBS, specific probiotics help reduce bloating/distension and improve bowel movement frequency/consistency. CONCLUSIONS This updated review indicates that specific probiotics are beneficial in certain lower GI problems, although many of the new publications did not report benefits of probiotics, possibly due to inclusion of new, less efficacious preparations. Specific probiotics can relieve lower GI symptoms in IBS, prevent diarrhoea associated with antibiotics and H. pylori eradication therapy, and show favourable safety. This study will help clinicians recommend/prescribe probiotics for specific symptoms.
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Tuck CJ, Vanner SJ. Dietary therapies for functional bowel symptoms: Recent advances, challenges, and future directions. Neurogastroenterol Motil 2018; 30. [PMID: 29094792 DOI: 10.1111/nmo.13238] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2017] [Accepted: 09/27/2017] [Indexed: 02/08/2023]
Abstract
BACKGROUND Functional gastrointestinal symptoms in irritable bowel syndrome (IBS) and quiescent inflammatory bowel disease (IBD) cause significant morbidity and a reduction in quality of life. Multiple dietary therapies are now available to treat these symptoms, but supporting evidence for many is limited. In addition to a further need for studies demonstrating efficacy and mechanism of action of dietary therapies, the risk of nutritional inadequacy, alterations to the microbiome and changes in quality of life are key concerns requiring elucidation. Identifying predictors of response to dietary therapy is an important goal as management could be tailored to the individual to target specific dietary components, and thereby reduce the level of dietary restriction necessary. PURPOSE This review discusses the available dietary therapies to treat symptoms in patients with IBS and patients with quiescent IBD suffering from IBS symptoms, with the aim to understand where current dietary evidence lies and how to move forward in dietary research in this field.
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Affiliation(s)
- C J Tuck
- Gastrointestinal Diseases Research Unit, Kingston General Hospital, Queen's University, Kingston, ON, Canada
| | - S J Vanner
- Gastrointestinal Diseases Research Unit, Kingston General Hospital, Queen's University, Kingston, ON, Canada
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Rezaie A, Rao S. Response to Tuck et al. Am J Gastroenterol 2017; 112:1886-1888. [PMID: 29215616 DOI: 10.1038/ajg.2017.382] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Affiliation(s)
- Ali Rezaie
- Department of Medicine, GI Motility Program, Division of Gastroenterology, Cedars-Sinai, Los Angeles, California, USA
| | - Satish Rao
- Division of Gastroenterology and Hepatology, Augusta University, Augusta, Georgia, USA
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Yao CK, Tuck CJ. The clinical value of breath hydrogen testing. J Gastroenterol Hepatol 2017; 32 Suppl 1:20-22. [PMID: 28244675 DOI: 10.1111/jgh.13689] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/14/2016] [Indexed: 12/22/2022]
Abstract
Breath hydrogen testing for assessing the presence of carbohydrate malabsorption is frequently applied to refine dietary restrictions on a low fermentable carbohydrate (FODMAP) diet. Its application has also been extended for the detection of small intestinal bacterial overgrowth. Recently, several caveats of its methodology and interpretation have emerged. A review of the evidence surrounding its application in the management of patients with a functional bowel disorder was performed. Studies were examined to assess limitations of testing methodology, interpretation of results, reproducibility, and how this relates to clinical symptoms. A wide heterogeneity in testing parameters, definition of positive/negative response, and the use of clinically irrelevant doses of test carbohydrate were common methodological limitations. These factors can subsequently impact the sensitivity, specificity, and false positive or negative detection rates. Evidence is also increasing on the poor intra-individual reproducibility in breath responses with repeated testing for fructose and lactulose. On the basis of these limitations, it is not surprising that the diagnosis of small intestinal bacterial overgrowth based on a lactulose breath test yields a wide prevalence rate and is unreliable. Finally, symptom induction during a breath test has been found to correlate poorly with the presence of carbohydrate malabsorption. The evidence suggests that breath hydrogen tests have limited clinical value in guiding clinical decision for the patient with a functional bowel disorder.
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Affiliation(s)
- Chu K Yao
- Department of Gastroenterology, Monash University and Alfred Hospital, Melbourne, Australia
| | - Caroline J Tuck
- Department of Gastroenterology, Monash University and Alfred Hospital, Melbourne, Australia
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Yao CK, Tuck CJ, Barrett JS, Canale KEK, Philpott HL, Gibson PR. Poor reproducibility of breath hydrogen testing: Implications for its application in functional bowel disorders. United European Gastroenterol J 2017; 5:284-292. [PMID: 28344797 PMCID: PMC5349363 DOI: 10.1177/2050640616657978] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2016] [Accepted: 06/11/2016] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Limited data are available regarding the reproducibility of lactulose and fructose breath testing for clinical application in functional bowel disorders. OBJECTIVES The purpose of this study was to investigate the reproducibility of lactulose and fructose breath hydrogen testing and assess symptom response to fructose testing. METHODS Results were analysed from 21 patients with functional bowel disorder with lactulose breath tests and 30 with fructose breath tests who completed another test >2 weeks later. Oro-caecal transit time, hydrogen responses, both qualitatively (positive/negative) and quantitatively (area under the curve (AUC) for hydrogen), were compared between tests. In another 36 patients, data scores for overall abdominal symptoms, abdominal pain, bloating, wind, nausea and fatigue were collected during the fructose test and compared to hydrogen responses. RESULTS No correlations were found for lactulose AUC (linear regression, p = 0.58) or transit time (Spearman's p = 0.54) between tests. A significant proportion (30%) lost the presence of fructose malabsorption (p < 0.01). Hydrogen AUC for fructose did not correlate between tests, (r = 0.28, p = 0.17) independent of time between testing (p = 0.82). Whilst patients with fructose malabsorption were more likely to report symptoms than those without (56% vs 17%; p = 0.04), changes in symptom severity were not different (p > 0.05). CONCLUSIONS Routine use of lactulose and fructose breath tests in functional bowel disorder patients is not supported due to its poor reproducibility and low predictive value for symptom responses.
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Affiliation(s)
- Chu K Yao
- Department of Gastroenterology, Monash
University and Alfred Hospital, Melbourne, Australia
| | - Caroline J Tuck
- Department of Gastroenterology, Monash
University and Alfred Hospital, Melbourne, Australia
| | - Jacqueline S Barrett
- Department of Gastroenterology, Monash
University and Alfred Hospital, Melbourne, Australia
| | - Kim EK Canale
- Department of Gastroenterology, Eastern
Health Clinical School, Box Hill, Australia
| | - Hamish L Philpott
- Department of Gastroenterology, Eastern
Health Clinical School, Box Hill, Australia
| | - Peter R Gibson
- Department of Gastroenterology, Monash
University and Alfred Hospital, Melbourne, Australia
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